7245 Ercp on intact papilla via long-limb roux-en-y gastrojejunostomy

• Published in: Gastrointestinal endoscopy 2000-04, Vol.51 (4), p.AB304-AB304
• Main Authors: Wright, Byron E., Freeman, Martin L., Cass, Oliver W.
• Format: Article
• Language: English
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/S0016-5107(00)14916-8

There are few reports of ERCP in patients with long limb roux-en-Y surgical anastamoses. The majority involve accessing biliary-enteric anastamoses, with very few reports of therapeutics on intact papillas. Methods: We reviewed all our consecutive ERCP attempted in 13 pts (23 total procedures) with long-limb gastrojejunostomy and intact papilla (no previous sphincterotomy (ES), stent, or biliary-enteric anastamosis). Data were abstracted from a prospective ERCP database and chart review. Results: Indications for ERCP included suspected sphincter of Oddi dysfunction (SOD) +/- pancreatitis in 9, obstructive jaundice in 3 and chronic pancreatitis in 1. 9 pts had gastric bypass for obesity and 4 partial gastrectomy, all with roux-en-Y gastrojejunostomy. 9 pts (11 procedures) had ERCP under general anesthesia, with mean duration of 137 mins (range 50- 255mins). Procedure was initiated with colonoscope or enteroscope to find jejuno-jejunal anastamosis (usually 60 cm from gastric remnant) and ascend correct (afferent) limb to papilla (additonal 60cm), followed by wireguided exchange for a duodenoscope to perform ERCP. The duodenoscope could be advanced to the major papilla during the first procedure in 9/13 (69%); a second attempt in 1 failed. Successful bile duct cannulation and therapy was ultimately achieved in all 9 patients in whom duodenoscope insertion was successful, with cannulation on first procedure attempt (7pts), second attempt (1pt) or third attempt (1pt). Intended pancreatography was successful in 1/1 pt. Biliary ES was performed in 8/9 (needle-knife over biliary stent in 6, and needle-knife precut access papillotomy after pancreatic stenting in 2).Wallstents were placed in 2, stone extracted in 1, and SO manometry performed in 2. Final diagnosis after successful ERCP in 9 pts was suspected or confirmed SOD in 5, malignant biliary obstruction in 2, malignancy plus biliary stone in 1, and chronic pancreatitis in 1. Complications included pancreatitis in 2 (1 mild, 1 moderate) and bleed in 1 (mild), all in pts with suspected SOD. Of 4 pts with unsuccessful ERCP, 2 were sent for surgical sphincteroplasty and 2 had no further procedures. Conclusions: Diagnostic and therapeutic ERCP was ultimately successful in about 2/3 of patients with long-limb gastrojejunostomies and intact papilla, limited primarily by ability to advance any scope up afferent limb to papilla. Successful ERCP allowed therapy for problems without easy alternatives, but often required